Open abdominal surgery: a risk factor for future laparoscopic surgery?

BACKGROUND: This study seeks to investigate the outcomes of laparoscopic procedures in patients with previous open abdominal surgery. METHODS: Using data from the National Surgical Quality Improvement Program (2005 to 2009), we identified patients who had undergone laparoscopic cholecystectomy, Nissen fundoplication, Heller myotomy, splenectomy, Roux-en-Y, sleeve gastrectomy, gastric band, appendectomy, or colectomy. Patients were then classified as to whether adhesiolysis (AD) was also carried out. Bivariate and multivariate analysis was used to compare groups. RESULTS: A total of 162,415 patients met our inclusion criteria, comprising 4,501 (3%) in the AD group and 157,913 (97%) in the nonadhesiolysis (NAD) group. Patient who had received lysis of adhesion were older, had 41% higher odds of overall complications, 17% higher adjusted mean lysis of adhesion (P < .001), and 26% higher adjusted mean operation duration (P < .001). CONCLUSIONS: A history of previous open abdominal surgery increases the potential complication rate and hospital length of stay during subsequent laparoscopic surgery. The extent of this relationship deserves further investigation.

Laparoscopic Repair of Sportman's Hernia - The Trinidad Experience.

Sportman's hernia: (Athletic pubalgia) is an uncommon and poorly understood condition afflicting athletic individuals. Sufferers complain of chronic groin pain and often present diagnostic dilemmas to physicians and physiotherapists. We present a series of cases illustrating the varying presentations of sportman's hernia and diagnostic approaches that can be utilized to exclude common differentials. We also describe laparoscopic mesh repair as an effective treatment option for this condition.

Racial/ethnic disparities in amputation and revascularization: a nationwide inpatient sample study.

This study investigates whether ethnic minorities presenting with critical limb ischemia (CLI) are more likely to undergo major limb amputation compared to white patients. The Nationwide Inpatient Sample (NIS) database was used to identify all patients admitted with CLI; lower extremity revascularization; and major lower extremity amputation from 1998 to 2005. The NIS identified 240 139 patients presenting with CLI--68.2% white, 19.5% black, 9.0% Hispanic, and 1.24% Asian. In all, 83 328 patients underwent revascularization--73.7% white, 15.9% black, 7.4% Hispanic, and 1.1% Asian. The majority of the interventions were open. In all, 111 548 patients underwent a major lower extremity amputation--61% white, 25.4% black, 10.1% Hispanic, and 1.1% Asian. The mean Charlson comorbidity scores for amputation were 2.1 for whites, 2.0 for blacks, 2.3 for Hispanics, and 2.5 for Asians (for all data, P < .05). Blacks make up a disproportionately higher proportion of patients admitted for CLI and undergoing amputation, with a lower proportion undergoing revascularization.

Portal vein thrombosis following laparoscopic cholecystectomy complicated by dengue viral infection: a case report.

INTRODUCTION: Portal vein thrombosis is an uncommon post-operative complication following abdominal surgery. Although therapeutic anticoagulation is recommended, this treatment may be questionable when the patient has an associated bleeding diathesis. CASE PRESENTATION: We report a case of a 63-year-old woman of Asian Indian ethnicity who developed portal vein thrombosis following an uneventful laparoscopic cholecystectomy for symptomatic gallstones. Her condition was further complicated by dengue viral infection in the post-operative period, with thrombocytopenia immediately preceding the diagnosis of portal vein thrombosis. The etiological connections between dengue viral infection with thrombocytopenia, laparoscopic cholecystectomy, portal vein thrombosis as well as the treatment dilemmas posed in treating a patient with portal vein thrombosis with a bleeding diathesis are discussed. CONCLUSION: When portal vein thrombosis occurs in patients with contraindications to anticoagulation, there is a role for initial conservative management without aggressive anticoagulation therapy and such patients must be approached on an individualized basis.

Negative appendectomy: a 10-year review of a nationally representative sample.

BACKGROUND: Appendectomy remains one of the most common emergency surgical procedures encountered throughout the United States. With improvements in diagnostic techniques, the efficiency of diagnosis has increased over the years. However, the entity of negative appendectomies still poses a dilemma because these are associated with unnecessary risks and costs to both patients and institutions. This study was conducted to show current statistics and trends in negative appendectomy rates in the United States. METHODS: A retrospective analysis was conducted using data from the National Inpatient Sample from 1998 to 2007. Adult patients (>18 y) having undergone appendectomies were identified by the appropriate International Classification of Diseases 9th revision codes. Patients with incidental appendectomy and those with appendiceal pathologies, also identified by relevant International Classification of Diseases 9th revision codes, were excluded. The remaining patients represent those who underwent an appendectomy without appendiceal disease. The patients then were stratified according to sex, women were classified further into younger (18-45 y) and older (>45 y) based on child-bearing age. The primary diagnoses subsequently were categorized by sex to identify the most common conditions mistaken for appendiceal disease in the 2 groups. RESULTS: Between 1998 and 2007, there were 475,651 cases of appendectomy that were isolated. Of these, 56,252 were negative appendectomies (11.83%). There was a consistent decrease in the negative appendectomy rates from 14.7% in 1998 to 8.47% in 2007. Women accounted for 71.6% of cases of negative appendectomy, and men accounted for 28.4%. The mortality rate was 1.07%, men were associated with a higher rate of mortality (1.93% vs .74%; P < .001). Ovarian cyst was the most common diagnosis mistaken for appendicitis in younger women, whereas malignant disease of the ovary was the most common condition mistaken for appendiceal disease in women ages 45 and older. The most common misdiagnosis in men was diverticulitis of the colon. CONCLUSIONS: There has been a consistent decline in the rates of negative appendectomy. This trend may be attributed to better diagnostics. Gynecologic conditions involving the ovary are the most common to be misdiagnosed as appendiceal disease in women.

Portal vein thrombosis following laparoscopic cholecystectomy complicated by dengue viral infection: a case report

INTRODUCTION: Portal vein thrombosis is an uncommon post-operative complication following abdominal surgery. Although therapeutic anticoagulation is recommended, this treatment may be questionable when the patient has an associated bleeding diathesis. CASE PRESENTATION: We report a case of a 63-year-old woman of Asian Indian ethnicity who developed portal vein thrombosis following an uneventful laparoscopic cholecystectomy for symptomatic gallstones. Her condition was further complicated by dengue viral infection in the post-operative period, with thrombocytopenia immediately preceding the diagnosis of portal vein thrombosis. The etiological connections between dengue viral infection with thrombocytopenia, laparoscopic cholecystectomy, portal vein thrombosis as well as the treatment dilemmas posed in treating a patient with portal vein thrombosis with a bleeding diathesis are discussed. CONCLUSION: When portal vein thrombosis occurs in patients with contraindications to anticoagulation, there is a role for initial conservative management without aggressive anticoagulation therapy and such patients must be approached on an individualized basis.

Laparoscopic splenectomy in a minimal resource setting: a case series from the Caribbean.

This study examines the perioperative outcome of laparoscopic splenectomy in a minimal resources setting in the Caribbean. Seventeen consecutive patients who underwent elective laparoscopic splenectomies by a single surgeon from August 2003 to December 2008 were studied. Data collected included patients' demographics, indications for surgery, operative time, complications, and outcome. 88% were females, the median age being 33.3 years. Idiopathic thrombocytopenic purpura was the most common indication (82%) in majority of the cases. Other indications included hereditary spherocytosis, hypersplenism, and metastatic disease. The mean operative time was 88.8 minutes and the mean hospital length of stay was 3.3 days. One case was converted to open splenectomy. Five patients experienced postoperative complications. There was no mortality. Despite limited blood banking facilities and hematology support, laparoscopic splenectomy may be safe in minimal resources setting, if cases are selected carefully and performed by an experienced surgeon with short operative times.

Laparoscopic splenectomy in a minimal resource setting: a case series from the Caribbean

This study examines the perioperative outcome of laparoscopic splenectomy in a minimal resources setting in the Caribbean. Seventeen consecutive patients who underwent elective laparoscopic splenectomies by a single surgeon from August 2003 to December 2008 were studied. Data collected included patients' demographics, indications for surgery, operative time, complications, and outcome. 88% were females, the median age being 33.3 years. Idiopathic thrombocytopenic purpura was the most common indication (82%) in majority of the cases. Other indications included hereditary spherocytosis, hypersplenism, and metastatic disease. The mean operative time was 88.8 minutes and the mean hospital length of stay was 3.3 days. One case was converted to open splenectomy. Five patients experienced postoperative complications. There was no mortality. Despite limited blood banking facilities and hematology support, laparoscopic splenectomy may be safe in minimal resources setting, if cases are selected carefully and performed by an experienced surgeon with short operative times

Bariatric surgery in the management of childhood obesity: should there be an age limit?

We report a case of a 6-year-old girl suffering from morbid obesity, Blount;s disease, and significant social and functional impairment who underwent a laparoscopic sleeve gastrectomy. One year later, she has shown remarkable improvement in all aspects of her health emphasizing the success of the procedure. A follow-up laparoscopic Roux-en-Y gastric bypass or biliopancreatic diversion (BPD) are options if she regains weight as she gets older. This case is noteworthy for several reasons. The age of the patient is younger than any currently on record who has had this treatment. Additionally, the utilization of a sleeve gastrectomy as a first-step procedure, to be followed by Roux-en-Y gastric bypass or BPD, remains a novel treatment for morbid obesity in a pediatric population.

Bariatric surgery in the management of childhood obesity: should there be an age limit?

We report a case of a 6-year-old girl suffering from morbid obesity, Blount;s disease, and significant social and functional impairment who underwent a laparoscopic sleeve gastrectomy. One year later, she has shown remarkable improvement in all aspects of her health emphasizing the success of the procedure. A follow-up laparoscopic Roux-en-Y gastric bypass or biliopancreatic diversion (BPD) are options if she regains weight as she gets older. This case is noteworthy for several reasons. The age of the patient is younger than any currently on record who has had this treatment. Additionally, the utilization of a sleeve gastrectomy as a first-step procedure, to be followed by Roux-en-Y gastric bypass or BPD, remains a novel treatment for morbid obesity in a pediatric population.

Gastrointestinal stromal tumor of the esophagus.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms that account for 0.2% of all GI neoplasms. We report a case of a 62-year-old male with a large esophageal GIST, and discuss the pathophysiology of the disease and the current management principles. This case is noteworthy because it documents a rare lesion in the esophagus that presents like other neoplastic diseases in this organ that usually carry a poor prognosis. An aggressive approach (e.g., more radical surgery, radiotherapy, and chemotherapy) might have been pondered based purely on the size of the lesion in this patient. It is important that primary care physicians and surgeons be aware of the possibility of the presence of this potentially curable lesion so as to avoid overtreatment.

Laparoscopic cholecystectomy: analysis of 619 consecutive cases in a Caribbean setting.

INTRODUCTION: Laparoscopic cholecystectomy has become the gold standard in the definitive treatment of symptomatic gall bladder disease. It boasts superior morbidity and mortality and lower complication rates than open approaches. AIM: This study outlines the experiences associated with 619 laparoscopic cholecystectomies performed in Trinidad. METHODS: The records of 619 consecutive patients who underwent the procedure were reviewed. All cases were either performed or supervised by the senior author. The population comprised 511 females and 108 males. The average age was 48.5 years. RESULTS: The commonest indications for surgery were symptomatic cholelithiasis (380 cases) and acute cholecystitis (111 cases). The mean operating time was 34 minutes. The mean length of stay on the ward was 17.45 hours. Mortality was zero. Only 4 cases were converted to open procedures. The commonest postoperative complication was wound-infection. CONCLUSION: In summary, this study demonstrates that laparoscopic cholecystectomy can be performed safely in a Third World setting with results comparable to those internationally.

Quality of life before and after laparoscopic Heller procedures--a Caribbean perspective.

BACKGROUND: The aim of this study was to compare the symptoms and quality of life before and after laparoscopic Heller myotomy within a Caribbean population. METHOD: Sixteen patients who were treated by the same surgeon were polled. The procedure was laparoscopic Heller myotomy with or without concomitant fundoplication. A specifically constructed questionnaire that assessed symptomatology and the quality of life (via social and emotional functioning scores) was administered. RESULTS: The mean age of the patients was 38.4 years; 11 were female and 5 were male. The mean preoperative duration of symptoms was 5.5 years (range, 1-13). All patients complained of dysphagia (liquids and solids), odynophagia, and preoperative regurgitation. Follow-up was completed with a mean postoperative duration of 16.7 months. Overall, symptoms improved by an average of 71.2%; social and emotional functioning improved by an average of 42.2% (p < .001). CONCLUSION: Laparoscopic Heller myotomy is extremely effective in improving the overall quality of life among achalasia patients within the Caribbean.

Quality of life before and after laparoscopic Heller procedures-a Caribbean perspective

BACKGROUND: The aim of this study was to compare the symptoms and quality of life before and after laparoscopic Heller myotomy within a Caribbean population. METHOD: Sixteen patients who were treated by the same surgeon were polled. The procedure was laparoscopic Heller myotomy with or without concomitant fundoplication. A specifically constructed questionnaire that assessed symptomatology and the quality of life (via social and emotional functioning scores) was administered. RESULTS: The mean age of the patients was 38.4 years; 11 were female and 5 were male. The mean preoperative duration of symptoms was 5.5 years (range, 1-13). All patients complained of dysphagia (liquids and solids), odynophagia, and preoperative regurgitation. Follow-up was completed with a mean postoperative duration of 16.7 months. Overall, symptoms improved by an average of 71.2%; social and emotional functioning improved by an average of 42.2% (p < .001). CONCLUSION: Laparoscopic Heller myotomy is extremely effective in improving the overall quality of life among achalasia patients within the Caribbean.

Laparoscopic cholecystectomy in sickle cell disease patients: does operating time matter?

OBJECTIVES: To report the experience of performing laparoscopic cholecystectomy (LC) in patients suffering from sickle cell disease (SCD), and to assess if their postoperative complications can be minimized by shortening the operating time. METHODS: Strict measures were taken to minimize the operating times and duration of pneumoperitoneum in SCD patients undergoing LC. Data collected included demographics, preoperative haemoglobin, the surgical technique used, operating times, insufflation pressures, perioperative complications and hospital length of stay. RESULTS: In the 5-year period from July 2003 to June 2008, 19 patients with SCD underwent elective LC. Of these, 84 per cent were female. The mean age was 21.5 years. The most common indication for surgery was symptomatic cholelithiasis (60 per cent). The mean preoperative haemoglobin was 8.2g/dL. No preoperative blood transfusions were given. Four patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP). Mean operating time was 27.9 min (range 20-45 min) which is 2.5-6 times quicker than most reports in the literature. There was no conversion to open surgery. Mean hospital length of stay was 2.5 days. Postoperative complications were noted in four patients with painful crises accounting for 50 per cent. There was no mortality. CONCLUSION: The study suggests that if stringent measures are taken to shorten the operating time, LC can be safely and effectively performed in SCD patients with minimal perioperative complications.

Laparoscopic cholecystectomy in sickle cell disease patients: does operating time matter?

OBJECTIVES: To report the experience of performing laparoscopic cholecystectomy (LC) in patients suffering from sickle cell disease (SCD), and to assess if their postoperative complications can be minimized by shortening the operating time. METHODS: Strict measures were taken to minimize the operating times and duration of pneumoperitoneum in SCD patients undergoing LC. Data collected included demographics, preoperative haemoglobin, the surgical technique used, operating times, insufflation pressures, perioperative complications and hospital length of stay. RESULTS: In the 5-year period from July 2003 to June 2008, 19 patients with SCD underwent elective LC. Of these, 84% were female. The mean age was 21.5 years. The most common indication for surgery was symptomatic cholelithiasis (60%). The mean preoperative haemoglobin was 8.2g/dL. No preoperative blood transfusions were given. Four patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP). Mean operating time was 27.9 min (range 20-45 min) which is 2.5-6 times quicker than most reports in the literature. There was no conversion to open surgery. Mean hospital length of stay was 2.5 days. Postoperative complications were noted in four patients with painful crises accounting for 50%. There was no mortality. CONCLUSION: The study suggests that if stringent measures are taken to shorten the operating time, LC can be safely and effectively performed in SCD patients with minimal perioperative complications.